Request for Repeat Prescription

St.Lukes & Botley Surgery - Medical Sick Note Request

Please allow a minimum of 5 working days for this request to be processed. Certificates may be back dated but cannot be issued in advance. Please print details clearly: Today’s Date:______Forenames: ______Surname:______Date of Birth:______Address: ______Post Code:______Tel No:______Not Fit to Work Certificate: Please provide full details in the box below of the reason for your absence from work and include details of your job title and role requirements:

Please confirm start date of certificate:______Please confirm finish / stop date of certificate:______Is this a continuation certificate: Yes:______No:______Where would you like to collect this sick note from? Botley □ St Lukes □

Which GP have you seen or knows the most about this condition? Dr Nadja Birch □ Dr Samantha Humphries □ Dr Elizabeth Fairfax □ Dr Rhodri Green □ Dr Fariha Zahid □ Other (ie: Hospital etc) □ Patients Signature:______

St.Lukes & Botley Surgery – Fit To Work Certificate Request

Please allow a minimum of 5 working days for this request to be processed. Certificates may be back dated but cannot be issued in advance. Please print details clearly: Today’s Date:______Forenames: ______Surname:______Date of Birth:______Address: ______Post Code:______Tel No:______Fit for Work Certificate: Please confirm the reason for this request by ticking one of the boxes below A phased return to work □ Workplace adaptation’s □ Amended working hours □ Other (please state why) □ Amended duties □ ______Where would you like to collect this certificate up from? Botley □ St Lukes □ Please provide details of occupation and the revised working pattern / amended duties you are seeking:

Which GP have you seen or knows the most about this condition? Dr Nadja Birch □ Dr Samantha Humphries □ Dr Elizabeth Fairfax □ Dr Rhodri Green □ Dr Fariha Zahid □ Other (ie: Hospital etc) □ Patients Signature:______